The scar on the inside of Seth Maness’ right arm looks like any other. It is maybe 2 inches long, a small streak of reddish purple that arcs along the crook of his elbow. Inside a baseball clubhouse, it is the mark of the beast. It is also everywhere.
The scar is a symbol of Tommy John surgery, the elbow reconstruction procedure that has changed how we think about sports medicine and the art of pitching. The scar is a reminder of the millions of dollars lost and the epidemic of pitcher injuries and the careers that hang by a tiny elbow ligament.
Yet on a May afternoon inside the Royals’ clubhouse at Kauffman Stadium, Maness, a 28-year-old middle reliever, twists his arm to his right, revealing his secret. This is no ordinary scar. This is one that could change the sport again.
Ten months ago, Maness, then a pitcher for the St. Louis Cardinals, had a torn ulnar collateral ligament in his right elbow, the injury that portends Tommy John surgery. On Sunday afternoon, Maness made his eighth relief appearance of the season for the Royals in an 8-0 loss to the Cleveland Indians.
The fact Maness is even here, back in the major leagues, pitching out of the Royals bullpen, makes his right elbow one of the most fascinating body parts in the game. Maness is less than a year removed from an injury that usually sidelines a pitcher for 12 to 16 months, and now he is back on the field, part trailblazer, part reliever, part patient zero in a potential medical breakthrough for elbow injuries.
“He’s a pioneer,” said Royals head trainer Nick Kenney.
In a 4-3 victory over the Orioles on May 13, Maness became the first to pitch a major-league game after undergoing a relatively new procedure called “Primary Repair,” an alternative to Tommy John surgery that could cut down the rehab process for a small percentage of ulnar collateral ligament injuries.
The surgery has the potential to extend or save careers, as well as millions of dollars for an industry beset by arm injuries. But for now, the procedure is so new, the data set so small, that medical experts and industry insiders are watching Maness with a combination of curiosity and hope. The new surgery might not fit every elbow. But in a sport where pitchers are breaking down at a dizzying rate — in the Royals’ clubhouse alone, Danny Duffy, Matt Strahm, Jason Vargas and Peter Moylan (twice) own Tommy John scars — that would be enough to make it a permanent part of the game.
“Think of the economic impact,” said Jeff Berry, the co-head of CAA Baseball and an agent who represents Maness. “Seth is a big test case. And a lot of the game is watching.”
In some ways, Maness is a reluctant pioneer. He is mild mannered and reserved, a native of Pinehurst, N.C., who played college ball at East Carolina and was drafted by the Cardinals in 2011. He simply wanted the ability to return to the big leagues as soon as possible. But in the weeks since returning to the majors in early May, he has dutifully told the story of his surgery, how a middle reliever with four years of big-league experience became the modern-day equivalent to Tommy John, the former major-league pitcher who is now more famous for his surgery than his 288 career wins or 26-year career.
Each time, Maness’ story comes with a similar line. This new surgery — “Primary Repair” — does not need to be named for him.
“They should name it after the doctor,” he said.
In this case, the doctor was George Paletta, the head orthopedic physician for the St. Louis Cardinals. Paletta is a prominent Tommy John surgeon who doubles as one of the leading thought leaders in the realm of Primary Repair.
In recent years, he began performing the new operation on dozens and dozens of select high school and college players. Aided by the technological advancement of suture materials, and similar to primary repair surgeries on knees and ankles in Europe, the elbow version has its origins around the year 2013. Paletta says he saw a way to get a young high school pitcher back on the field for his senior year. But before Maness, he had not found the right major-leaguer on which to perform the procedure.
Unlike Tommy John surgery — which came to be in the 1970s and includes the replacement of the ulnar collateral ligament with a tendon graft — Primary Repair includes the re-attachment and reinforcement of the old ligament to the bone. In the case of Tommy John surgery, Paletta says, the biological integration of the transplanted tissue involves developing a new blood supply — part of the operation includes drilling holes into the humerus and ulna bones in which the new tendon can be looped around. This causes the rehab process to stretch out to 12 to 16 months. But in Primary Repair, the healing of native ligament to bone occurs in a more predictable manner. That cuts down on the recovery timeline.
This was the procedure that Paletta believed could offer Maness a path to a quicker recovery. But to be eligible, the tear of the ulnar collateral ligament has to be at or near the bone. The remaining tissue of the ligament also has to be of good quality. In younger patients, the latter is more likely to be the case. This is for somewhat obvious reasons: After a decade of throwing a baseball harder than 90 mph, most professional pitchers have a ligament with significant damage.
Still, based on MRIs, Paletta believed that the procedure might work for Maness. But until he opened him up, he would not know for sure. So on Aug. 18, 2016, Maness went into surgery, not knowing whether he would have a regular Tommy John operation or the other one. As he woke up that day, still a little groggy, Paletta came into the room. It was good news.
“That was the first question I asked,” Maness said. “Were they able to do the one with the shorter recovery time? … I was still a little loopy.”
From there, Maness attacked the rehab process, hopeful that he could return for opening day in 2017, still less than eight months away. He didn’t achieve that goal, but the results were still impressive. In February, he signed a minor-league contract with the Royals, who understood the medical process and viewed the signing as low risk. By May 1, he was making his first appearance at Class AAA Omaha. In 9 2/3 innings with the Royals through June 5, he has allowed four earned runs, logging a 3.72 ERA, a half-run higher than his career mark of 3.21. He was optioned back to Omaha on Tuesday to clear space for Jake Junis’ spot start.
For Maness, a reliever, the quick return was paramount. If he would have undergone Tommy John surgery, he would have likely missed all of 2017 and remained unemployed until 2018. He would have been viewed skeptically by a baseball industry that considers middle relievers expendable. But after Primary Repair and an offseason of work, he was back in the major leagues.
“If he would have had Tommy John, he’s at home,” said Berry, the agent. “He’s not in the big leagues. And so it gave him the ability to go in and work into it in spring training and get himself back.”
Here, of course, it’s important to note that Maness may yet be an anomaly. It’s impossible to know what percentage of major-league pitchers might be eligible for Primary Repair after injuring their ulnar collateral ligament. Paletta believes the number could be close to 20 percent. Others offer a more cautious estimate. There is still so much to learn, Paletta says. But this could be the start. The data from the surgeries involving amateur baseball players is promising. And Maness is back in the major leagues. He’s pitching again, the scar visible every day he steps on the mound. And for now, the medical field is watching.
“It’s going to be critical that we follow these athletes carefully and be selective in whom we perform this procedure,” Paletta said. “If the results bear out over the long term as they have over the short term, it may really make a difference.”